How nutrition research is helping young gymnasts and figure skaters stay healthy

What young performing artist athletes eat today will make a big difference tomorrow.

Dancer Mia Steedle, 18, receives nutrition coaching from sports medicine staff at Boston Children’s through its work with Boston Ballet.Aram Boghosian for the Boston Globe

The years of arabesques, pirouettes, and high-impact landings began to take their toll.

Mia Steedle started dancing with Boston Ballet School when she was 3 years old. She saw doctors at Boston Children’s Hospital through the years for the occasional injury. But at age 15, the recurring pain in her foot told her something was wrong.

That’s when two health care practitioners from Boston Children’s who work closely with Boston Ballet took center stage in her care. Dr. Bridget Quinn, a sports medicine specialist, diagnosed Steedle’s injury as damage caused by bone overuse. Because adolescent bone development is closely linked with nutrition, Quinn referred the teen ballerina to Laura Moretti, a clinical nutrition specialist in the hospital’s female athlete program and a consulting dietitian for Boston Ballet and its schools.

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Moretti, a competitive triathlete and Boston Marathoner, manages the nutritional care of a spectrum of young athletes and performers — sick, injured, and well. At Boston Ballet, she advises world-class dancers on “fueling” strategy when they are healthy and treats them when things go wrong. “There is a tremendous amount of evidence showing that an adequate amount of calories — especially the carbohydrates — is injury preventive and performance enhancing,” Moretti says.

Young athletes whose bodies are still developing — and in particular “artist-athletes,” such as dancers, cheerleaders, gymnasts, and figure skaters — need to focus on what and when they eat to maintain health and peak performance. The physical and mental rigors of their activities require careful meal planning that ensures adequate energy. This “mindful eating” helps stave off illness and injury that can sideline performers. Quinn and Moretti are medical staff in the performing artist athletes program at Boston Children’s, which offers these athletes one of the few clinics dedicated to their special needs, with a view toward their long-term health.

“Anybody that’s trained in orthopedics can take care of . . . the sprained ligament, or the MCL [medial collateral ligament]. We look at how a young artist-athlete’s injury can affect their health in 20 or 30 or 40 years,” says Dr. Andrea Stracciolini, a primary care sports medicine physician and director of dance medicine at Boston Children’s. “We are absolutely forward looking. Bone development is directly correlated with nutrition.”

That philosophy of the childhood-through-adulthood arc of care is echoed by Moretti: “Girls stop building bone density at about age 22; for males, it’s more like mid-20s.”

For elite dancers in the Boston Ballet Company, which includes young ballerinas like Steedle, a seven-hour day of rehearsals, training, and performance is not unusual. Inevitably, that kind of rigorous routine — compounded by the natural anxiety that comes with performing — can break down the body’s systems if athletes aren’t consuming enough calories. “We are beginning to see injuries as a result of that caloric deficit; it might be stress fractures, fatigue, [gastrointestinal] issues,” Moretti says.

“I was eating three meals a day, but I wasn’t thinking about the specifics of what went into that,” Mia Steedle says. Aram Boghosian for The Boston Globe

For Moretti, the most important therapy is education. She stresses to her patients, for example, the threat of a condition called the female athlete triad. Since at least 1992, sports physicians have recognized this syndrome as a complex interrelationship of bone density problems, low energy availability, and menstrual dysfunction, experienced by as many as 50 percent of highly active girls and women. The key to prevention is paying attention to nutritional intake throughout the day.

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Dr. Quinn, an expert on the condition, explains that she and her colleagues are now viewing the problem as one element in a wider disorder recently designated as relative energy deficiency in sport, or RED-S. “We are now aware that it affects both women and men,” she says. A 2018 review in the British Journal of Sports Medicine reports that because there is no methodology to screen and identify athletes at risk for RED-S, it often goes undiagnosed in females and is even more frequently missed in males.

Dr. Kathryn Ackerman, director of the female athlete program, studied 1,000 patients to determine the performance and health effects of RED-S in girls and women who are active in sports. The International Olympic Committee used her research in its 2018 consensus statement aiming to spur awareness of the condition and research into addressing it.

Left untreated, RED-S can contribute to osteoporosis, cardiovascular dysfunction, and other systemic ailments. While treatment requires a physician trained in sports medicine, the female athlete program team broadly advocates a diet of macronutrients (a balance of proteins, carbohydrates, and fats), micronutrients (vitamins and minerals), iron, calcium, and lots of water for all participants in youth sports.

“Following the nutrition plan has improved my overall health and performance level,” says Steedle, now 18. “Before I went to see [Moretti], I didn’t know about it. I was eating three meals a day, but I wasn’t thinking about the specifics of what went into that and what that means in terms of it directly affecting my ability to dance.” Steedle hasn’t had any injuries since she started paying closer attention to her eating habits.

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Shortly before a production opens, she and her Boston Ballet colleagues often start their days at 9:45 a.m. with classroom rehearsals and don’t stop until final curtain at 10:30 p.m. “It can be quite a lot to fit three meals and recovery snacks into a schedule, Steedle says. “It’s a mentality — you have to work eating into your daily life.”

Through the winter Nutcracker season, the annual holiday marathon that involves more than 300 dancers performing 44 shows in five weeks, Steedle drinks a carton of chocolate milk before every performance. “As long as I had that,” she says, “I knew it was going to be a good show.”

While Steedle doesn’t count calories, she does make sure to load up on carbohydrates, which for dancers should be half of their daily calories. But breakfast for her is typically a classic American protein bomb: egg and cheese omelet with sausage. For the occasional carbohydrate blast? “I like tater tots and love ice cream,” Steedle says.

Tater tots and ice cream are not the first foods that Moretti recommends — she emphasizes complex carbohydrates like whole grains and fresh fruits and vegetables — but the occasional indulgence is not forbidden: “There are no bad foods,” she says. “I am a dietitian who doesn’t like diets.”

Her bottom line? “I am trying to keep them from losing too much weight. So much of my job is about adequate calories and fueling bodies,” she says. “When you watch a dancer who is well fueled, you see the power within the grace.”